Cultural Considerations in the Delivery of Dental Services to the Hispanic Community

1. Cultural Considerations in the Delivery of Dental Services to the Hispanic Community E. Angeles Martínez-Mier, DDS, MSD, PhD Ana G. Gossweiler, DDS, MSD

2. U.S. Demographics • Rapidly becoming more diverse • Minority populations growing at a fast pace • Hispanic group becoming the largest minority group in the U.S.

3. Indiana Demographics • Population has tripled between 1990 and 2002 • Mexicans 60% • Median age 25 • 13% of the population in Indiana • Indianapolis 65 000 to 85 0000 according to local studies

4. Hispanics or Latinos in Indiana • Hispanics or Latinos of any race 214,536 Mexican 153,042 Puerto Rican 19,678 Cuban 2,754 Others 39,062 U.S. Census Bureau, Census 2000

5. Culture • What is it? • Where is it found? • Who has it? • When is it used? • Why is it important?

6. Culture • The skills, art, etc., of a given people in a given period, civilization Webster’s New World Dictionary

7. Culture • Culture is: • Guides how people live • What they believe and value • How they communicate • What are their habits, customs and tastes • Guides the ways they meet various needs of society • How goods and services are produced and distributed Slide by Valery Yontz, PhD, University of Hawaii

8. Definitions • Cross-cultural • Intercultural • Subculture • Values • Beliefs • Stereotyping • Ethnocentrism

9. Cross-cultural • Refers to any comparison of cultural differences or the situations in which such differences exist

10. Intercultural • Refers to the actual interaction between people of different cultures

11. Subculture • Formed by a group of persons who have developed interests or goals different from the primary culture, based on such things as occupation, sex, age, social class, or religion.

12. Values • Ideas about what is right and wrong, desirable and undesirable, normal and abnormal, proper and improper • A set of organized rules for making choices, reducing uncertainty and reducing conflicts within a given society

13. Beliefs • Belief is a psychological state in which an individual holds a premise or an argument to be true without necessarily being able to adequately prove their point to other people who may or may not agree.

14. Stereotyping • Refers to the common behavior of assuming that individuals possess certain characteristics or traits because they are members of a particular group. Fails to recognize the individual

15. Ethnocentrism • Natural belief that one’s culture is superior to that of others • Care is needed not to demean clients whose oral health practices may be rooted in culture rather than scientific fact

16. Iceberg Concept Is the culture always visible to the observer? Primarily in Awareness Primarily out of Awareness

17. Primarily in Awareness • Fine arts • Literature • Drama • Music • Dancing • Games • Cooking • Dress May be obvious to the observer

18. Primarily Out of Awareness Not necessarily obvious to the observer • Notions of modesty • Conceptions of beauty • Patterns for handling emotions • Conception of self • Conception of justice • Decision making patterns • Attitudes toward the dependent • Patterns of superior/subordinate relationship

19. Health Care Issues Related to Culture • Culture influences: - communication (language, tone, nonverbal communication) - trust - behavior - understanding wellness and illness - seeking health care - receiving and complying with care

20. Cultural Competency’s Definition • The ongoing process of actively developing and practicing appropriate, relevant, and sensitive strategies and skills in interacting with culturally different people. Includes the capacity to respond appropriately to the needs of populations whose cultures are different from what might be “the dominant or mainstream culture.” Slide by Valery Yontz, PhD, University of Hawaii

21. Goals of Cultural Competency • Self- exploration • Personal development • Attitude and values clarification • Ethnic and cultural literacy • Empowerment—equality and excellence • Basic skills proficiency • Social competency Slide by Valery Yontz, PhD, University of Hawaii

22. Skills and Characteristics of Cultural Competency • Respectful • Willingness to share, risk change,& explore • Understand the power of action and words • Ability to recognize learning opportunities • Possessing knowledge of one’s self • Being aware of ignorance • Having attitude that “Different is okay: not good or bad Slide by Valery Yontz, PhD, University of Hawaii

23. Right or Wrong • “We must be able to recognize and deal with beliefs of others if we wish to obtain communication.” Samovar & Porter Intercultural Communication

24. Good Bad http://www.yourpointofview.com/

25. Bad Good http://www.yourpointofview.com/

26. Cultural Competency Components • Develop an awareness of one’s own existence • Demonstrate knowledge and understanding of other cultures • Accepting/respecting cultural differences • Stop assuming that others’ beliefs and values are the same as yours • Stop judging attitudes as good or bad • Be open to range of cultural encounters • Adapt to be congruent with other cultured persons Slide by Valery Yontz, PhD, University of Hawaii

27. Cross’s Cultural Competency Continuum • Cultural destructiveness • Cultural incapacity • Cultural blindness • Cultural pre-competence • Cultural competence • Cultural proficiency • Cross, T; 2001 Slide by Valery Yontz, PhD, University of Hawaii

28. Why is cultural competenceimportant to dental professionals? • It assist in recognizing the elements of culture that are relevant during a patient care (communication issues, religion, family networks, gender norms, sense of humor, etc…)

29. Benefits of gaining intercultural competence • Provide compatible messages with patient’s cultural values and beliefs • Increase the relevancy of health education • Increase effectiveness of dental care with a diverse client • Increase a practitioner’s multicultural knowledge

30. Cultural Assessment Domains • Ethnic identity/history • Communication • Activities of daily living • Orientation to time • Food practices • Family relationships • Birth and death rituals • Spiritual/religious orientation • Bio-cultural ecology • Illness beliefs • High-risk behaviors • Health practices and practitioners Slide by Valery Yontz, PhD, University of Hawaii

31. Hispanics/Latinos: Key Cultural Points • Ethnic Identity and History • Latin America designates all those countries and territories in the Americas where languages derived from Latin are spoken: Spanish, Portuguese, French, and their creoles. • The region was home to many indigenous peoples and advanced civilizations (Aztecs, Mayan, and Incas). With the arrival of the Europeans the indigenous peoples lost power to the Europeans. European powers, most notably Spain and Portugal, colonized the region. After independence movements, the countries of the region became independent by the late 19th century.

32. People in Latin America are a mixture of many racial groups. Their origins include over 22 countries While Spanish is usually the common language, there is a wide variety of idiomatic speech patterns and dialects Diversity within the Hispanic Community

33. Diversity = Mix of Cultures

34. Hispanics/Latinos: Key Cultural Points • Communication • Casual conversation prior to “the point” • Resistance to lose language • Maintain outward expressions of dignity and calm • Touching, kissing, hugging between family in public • Make eye contact, hold hands, hug

35. Hispanics/Latinos: Key Cultural Points • Activities of Daily Living (ADLs) • Respect for tradition • Hard working • Follow cultural/family practices, cleaning, cooking, etc. (practice of traditional things in the U.S.)

36. Collectivism • Latinos prefer the company of others versus being alone. • Sharing is an activity that is an outgrowth of collectivism. • Drinking alcohol and smoking are experiences that are shared with other friends. • How long a man drinks with his friends is often determined by when his wife arrives to tell him it is time to come home. • Chong, The Latino Patient

37. Hispanics/Latinos: Key Cultural Points • Orientation to Time • Flexible sense of time • Food Practices • Very traditional • Special events • Family traditions

38. Hispanics/Latinos: Key Cultural Points • Family Relationships • Connectedness to extended family • Children taught to repress aggressive and assertive behavior • Machismo/Marianismo

39. Cultural values and gender • Machismo • refers to the man’s masculinity and puts the man at the center of the social life. It is exhibited through courage and authoritarian attitude • Marianismo • Refers to the woman’s position at home and in the family. A woman earns respect through her dedication to her children and husband

40. Cultural values and gender • As the need for income increases, there is greater financial pressure on the wife to enter the workforce. • As she contributes to the family income, she will attain more independence and greater parity in the family decision making process. • Her exposure to the workplace and her social contacts outside the home will tend to accelerate the process of acculturation.

41. Hispanics/Latinos: Key Cultural Points • Birth and Death Rituals • Male/Female roles well defined during funeral and births • Women pampered more during pregnancy • Cultural traditions practiced at funerals

42. Hispanics/Latinos: Key Cultural Points • Spiritual and Religious Orientation • Catholics • Some develop special relationships with saints • Some superstitions • Sacrifice in the world is helpful to salvation

43. Hispanics/Latinos: Key Cultural Points • Bio-Cultural Ecology • Higher caries, periodontal disease prevalence. Lower prevalence of oral pharyngeal cancer • Physical appearance: From American Indian to European characteristics

44. Hispanics/Latinos: Key Cultural Points • Illness Beliefs • Illness result of bad luck or God’s punishment. The causes of some illness are found outside the body. Powers of good and evil. • Illness prevented by proper diet, wearing amulets, use of candles, avoiding harmful people • May use combination of folk and Western Medicine

45. Folk Healers • Use of Natural Healers / Curanderos / SpiritistsHarmful Magic: Evil-eye/Mal de ojo: Excessive admirationFright/Susto: Associated with a traumatic experienceEvil-hex/Mal Puesto: Motivated by jealousy or vengeanceGomez 1977

46. Folk Medicine

47. Perception of Health and Education • Educated Latinos: • Healthy refers to “a state of complete physical, mental, and social well-being and not merely the absence of disease.” • World Health Organization • Less Educated Latinos: • Health has a religious perspective. Disease is seeing as a warning or punishment • God is the giver of all, including my health

48. Hispanics/Latinos: Key Cultural Points • High Risk Behaviors • Diet • Infants should “eat well” • “No come bien” • Bottle feeding at night

49. Nutritional habits and acculturation • The Latino/Hispanic diet is very diverse. But, in general the diet is low in vegetable fats and high in fiber content when compared with non-Latino whites diets • The less acculturated the Hispanic patient is, the more likely they are to eat fruits, rice, beans, meat, fried food and whole milk • More acculturated Latinos have diets that are a risk factor for obesity, diabetes and hypertension • Alcalay et al. 1999, Otero-Sabogal et al. 1995, Alcalay et al. 1992

50. Hispanics/Latinos: Key Cultural Points • Health Practices and Practitioners • Family care for young and old • Discuss health of family members • Respond well to individualized attention